By Henry Schneiderman MD, Vice President for Medical Services and
Physician-in-Chief, Hebrew Health Care
So, if pain has not been relieved by a thorough trial of full-dose acetaminophen, and one wisely considers the NSAIDs too unsafe, what measures are available:
1) Nonpharmacologic relief: numerous compelling studies demonstrate efficacy of non-medication measures. Warm packs prove very helpful to promote healing, largely by augmenting regional blood flow, and to relieve discomfort”all the more so when muscle spasm exacerbates pain as is the case in a great many musculoskeletal injuries and problems whether they start out with muscle strain or not. Topical cooling can also play a key role, particularly reduction of blood flow relieves swelling. Neither modality is to be abused: burns or frostbite are not in the plan. Package inserts from a popular disposable heating products, Therma-Care, cover the essentials: don’t use on a body part that lacks proper sensation, so that you don’t discover a burn by smelling it, don’t exceed the manufacturer’s recommended duration of application, don’t apply over a sore, don’t use on a part of the body with known impaired blood supply whether arterial or venous.
Therapeutic exercise of muscles that act on a sore joint stabilizes the joint over time and so reduce pain, for instance in ordinary knee arthritis. Crucial elements include professional oversight, which usually means a physical therapist in the loop; and continuing to perform the exercise regularly even after the initial pain has eased. Sometimes a very simple soft brace strap can keep a tendon from slipping out of kilter. Don’t just purchase what looks promising at CVS: consult a professional.
2) Propoxyphene (Darvon; and others): Combinations of this with other medications go by names including Darvon Compound and Darvocet N-100. Avoid these like the plague! For 35 years they have been documented as causing numerous deaths. Many persons swear by them but there are ALWAYS safer and more effective options.
3) Aspirin: Aspirin works wonderfully at preventing and treating heart attacks and strokes; and reduces risk of colon cancer. However, it is an NSAID, so no reader of the prior columns will be surprised to hear that though I have myself swallowed a baby aspirin every morning for more than 20 years for these purposes, I disagree with the manufacturer’s claim that additional doses can be used for pain relief. Aspirin is notorious for causing stomach bleeding. Many patients must not take it at all, including those with prior bleeding problems, active stomach ulcers, low platelet counts, true aspirin allergy, or risk for Reyes syndrome that causes brain damage when flu-like symptoms under age 25 are treated with aspirin.
The only pain that should trigger aspirin is chest pain suggesting a heart attack. In that case you need to be seen in an Emergency Department at once. If you are having such pain and reading this column to figure out what to do:
a. stop reading NOW
b. dial 911 NOW
c. THEN and only then, and only if you are not forbidden aspirin, chew up 4 baby aspirin or one adult-size aspirin, while you wait for the ambulance to get to you.
4) Tramadol (Ultram): This drug was developed to fill a perceived gap between pain that could be relieved by acetaminophen and pain requiring opiates. Like many a compromise, it achieves partial success. Some persons find great relief from tramadol. Others are less satisfied. Concerns about liver toxicity often make doctors reduce the prescribed doses. Tramadol is a niche medicine, very helpful to some but not a panacea. Pain that can’t be controlled on this drug and that is not neuropathic means it is time to consider opiates.
5) Neuropathic pain: Some pain results not from nociception, the body’s discerning tissue injury, but from signal misperception in nerve cells and their connections in the brain. Examples include the pain felt by some diabetics in perfectly healthy limbs, or phantom but absolutely NOT psychogenic pain experienced by an amputee in a limb that is no longer on the body! A substantial fraction of “regular” pain may also embody neuropathic mechanisms. Neuropathic pain is uniquely amenable to some medicines that help the brain powerfully in this condition despite modest or minimal anti-pain effect in ordinary nociceptive pain. The three leading such medicines are gabapentin (Neurontin), duloxitene (Cymbalta) and pregabalin (Lyrica). Each carries a formidable list of potential side effects, the weight gain experienced by many persons who take pregabalin being one sidestepped in the blizzard of television commercials. Each has some other activities such as antidepressant or anti-seizure, but for all, the anti-pain activity is not caused by these other properties. A medicine best known as a pure topical anesthetic also turns out to have anti-neuropathic activity: the LidoDerm patch, a topical lidocaine delivery system. Patients with undiagnosed neuropathic pain are often stunned at how much better they feel, and with how much less fuss, when given the right one(s) of these medicines.
6) Corticosteroids: When inflammation causes pain, clearing out the inflammation can be optimal; the expectation is that the pain will follow. NSAIDs combat pain and inflammation all at once, so if they were not so dangerous, they could be seen as ideal: clear up the cause and the effect all at once.
Some inflammation is best treated by eradicating its source, as when an antifungal medicine obliterates infection that leads to inflammation that makes a toe with athlete’s foot burn. In this setting, an anti-inflammatory approach would not be wise. However, there are conditions wherein prednisone or other corticosteroid medicine whether topical or systemic, makes all the difference. The possible adverse effects are legion, from crinkly skin to heart failure to uncontrolled hypertension to worsening or triggering diabetes, the safest use of these medicines requires a highly attentive and skilled physician or nurse practitioner.
7) Opiates: The very group name is more acceptable to the public than its equally sound scientific synonym, the narcotics.
The prototype of this class of drug is morphine sulfate. The public has an utterly unrealistic view of morphine as something reserved for the end of life”an impression foisted by old movies among other sources of misinformation that we fail to update critically. Morphine is also a superb drug for the middle of life. It not only relieves pain, but also confers two other separate and distinct benefits: relief of anxiety, and relief of breathlessness. Almost nobody requires injection to receive morphine. It is available orally for both immediate-release (MS-IR and other brands) and sustained-release (MS-Contin and other brands). A concentrated form is released to the bloodstream from under the tongue (Roxanol and other brands). This means that anybody who needs a maintenance dose in the middle of the night need not be awakened to swallow it!
Morphine (and its relatives) work well because they fit a pre-existing brain system, the endorphins; they are a lock and key for a means that the brain already possesses to ameliorate suffering. Hence their superior efficacy over all alternatives comes as no surprise.
Addiction concerns about opiates are wildly exaggerated in our society. Persons who have not had substance dependency before, and who receive responsible counsel and prescriptions, are most unlikely to become addicted and to display escalating drug requirements. Most physicians who specialize in pain management agree that we deny helpful drugs which sustain quality of life to too many persons because of inappropriate concern that we will create addicts”something nobody wants to do, of course.
Codeine is a widely used opiate. Many persons regard it as more familiar and less frightening, a kind of “morphine lite”. The trouble is, a substantial minority of the population lacks an enzyme to convert this drug into its active form. These persons get NO BENEFIT from the drug. Of course when a patient protests “The drug is not working, please give more”, the clinician is likely to misinfer drug-seeking and to become judgmental and withholding, rather than simply to change medicine. By the way, codeine is also unique as an anti-cough agent.
Oxycodone is another crucial member of the opiates, whether in its short-acting form or in the long-acting oxycontin that has become notorious because of abuse by persons who use it to get high or to sell for criminal profit. Hydromorphone (Dilaudid) is an opiate often chosen as safest for persons with reduced kidney function, though also useful for any person who needs opiates.
A transdermal opiate patch is called the fentanyl patch (Duragesic and other brands). While a patch sounds highly appealing for the person who “hates pills”:
a. One need take no pill to use concentrated liquid morphine;
b. The patch is far more expensive
c. For persons who are very thin, patches do not work properly
d. The patch works by creating equilibrium between a depot of the drug that forms under the skin, and the bloodstream. This means that pain relief does not occur for a solid 24 hours after the drug is begun or the dose increased”sometimes even longer; equally troublesome, if dose reduction is needed, removing the patch will only lower drug levels in the bloodstream after 24 hours have passed.
Let me educate you more about opiates:
1. The body adapts to use of opiates. All the well-known side effects such as confusion and low BP tend to ease and clear with continued use beyond a few days. The single exception is constipation. So, if you are going to be taking an opiate, make sure you have a laxative, ideally a stimulant such as senna, or something gentler such as polyethylene glycol 3350 (Miralax).
2. No mainstream doctor uses opiates to hasten death, notwithstanding Doctor Kevorkian. These drugs are used safely to reduce discomfort and suffering. Close monitoring of breathing and blood pressure need only be maintained for a short time on starting and with increases. To withhold opiates due to overblown and misrepresented concerns is inexcusable.
3. There is no maximal tolerable dose of opiate. If a pain source is dreadful, dose increases can be done safely, under supervision, so that few or no persons should have to put up with severe pain, or have to be drowsy to avoid intense pain.
4. Chronic pain does not manifest in the same behaviors as does acute pain. We need to be on guard against concluding that a chronic pain is mild or well-controlled just because the face is not drawn, or the person is able to sleep, or the pulse is not racing. We have no laboratory test to quantify pain, nor any perfect physical finding on examination. A basic tenet is to believe the patient, not naively, but emphatically. On this analogy I will end: I give something to any beggar who asks me; I realize that sometimes I am being conned, and that some are not in need, and that some will go spend the money on crack cocaine. But are we to test for need and veracity so hard that we risk missing a chance, in this short and precious life granted to each of us, to bring a little mercy into the world, to reduce suffering where we can?